Document cortlandcountyny_gov_doc_2e965ff175

A nonprofit independent licensee of the BlueCross BlueShield Association DEPENDENT CERTIFICATION FORM 1- Subscriber and Dependent Information SUBSCRIBER'S LAST NAME DEPENDENT'S LAST NAME SUBSCRIBER'S FIRST NAME INITIAL IDENTIFICATION NUMBER DEPENDENT'S DATE OF BIRTH INITIAL DEPENDENT'S FIRST NAME mm dd yyyy 2- Does the dependent have any other insurance coverage? NO, please continue to question #3 YES, please answer the following: a) Type of Coverage: Medical b) Other Insurance Carrier ID Dental and/or c) Effective Date of Other Insurance Coverage: mm dd yyyy d) Other Insurance Company: Excellus BlueCross BlueShield Other BlueCross BlueShield Plan, indicate plan name: Other Carrier, indicate plan name: 3- Is the dependent married? NO, continue to question #4 YES, please indicate marriage date: yyyy mm dd 4- Is the dependent currently enrolled as a full-time student at an accredited school/college? YES, please answer the following: a) Name of Accredited School/College: b) Expected Graduation Date: mm dd yyyy Yes No c) Will the dependent continue on to further education after graduation? NO, please answer the following: a) Date Student Status Ended: mm dd yyyy b) Reason Student Status Ended: Graduated Voluntary Disenrollment Medically Necessary Leave of Absence Your dependent may be entitled to continue coverage for up to six months for a medically necessary leave of absence that: starts when the child is suffering from a serious illness or injury, is certified by a physician as medically necessary; and causes the child to lose student status for coverage under your plan. Along with this form, a 'Continued Student Coverage Request For Medically Necessary Leave of Absence' form, completed by you or the member and the dependent's physician, must be submitted. The form can be obtained from our Web site at or by contacting our Customer Care department at the phone number listed on your member card. Other: 5- Signature and Date I certify that the information submitted is accurate to the best of my knowledge. SIGNATURE: DATE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. I have thoroughly read, understand and agree to comply with the terms of the release. Please ensure that all sections are complete, signed, and dated prior to returning. Failure to supply all of the required information may result in delayed processing and/or subsequent return or denial of this request. P.O. Box Please return completed form to: B-3020 01/10 ---PAGE BREAK---     ' 5*7
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7/8;6*=287
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27
8=1.;
5*70>*0.<
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8A

 
 Health Plan’s Civil Rights Coordinator //2,.
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 ---PAGE BREAK--- .-2,*2-
55*6.
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 5*7
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 ⌘᜿˖ྲ᷌ᛘ䈤ѝ᮷ˈᛘਟݽ䍩㧧ᗇ䈝䀰ॿࣙᴽ࣑DŽྲ᷌ᛘᱟ125-
.*5=1
5><
ᡆ .-2,*2-
Պઈˈ䈧ᤘᢃ  5*7 Պઈˈ䈧ᤘᢃ  DŽྲ䶎к䘠Պઈˈ䈧ᛘᤘᢃ  Внимание! Если ваш родной язык русский, вам могут быть предоставлены бесплатные переводческие услуги. Если вы являетесь участником программы Child Health Plus или Managed Medicaid, позвоните по телефону 4359. Если вы являетесь участником программы Essential Plan, позвоните по телефону 9298. Всех остальных просим звонить по телефону  ;.BL5
B2
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#2
8>
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B87
6*76
125-
.*5=1
 B87
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<<.7=2*5
5*7
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726.@8
 㚀⥘☐⫱⏼␘
䚐ạ㛨⪰㇠㟝䚌㐐⏈ᷱ㟤
ⱨ⨀㛬㛨㫴㠄㡸ⵏ㡰㐘㍌㢼㏩⏼␘
125-
.*5=1
.-2,*2-
䟀㠄㢨㐔ᷱ㟤
 
ⶼ㡰⦐㤸䞈䚨㨰㐡㐐㝘
<<.7=2*5
5*7
䟀㠄㢨㐔ᷱ㟤

ⶼ㡰⦐㤸䞈䚨㨰㐡㐐㝘
ὤ䇴㢌ᷱ㟤  ⶼ㡰⦐㤸䞈䚨㨰㐡㐐㝘
Attenzione: Se la vostra lingua parlata è 7>6.;8
 5*7
,12*6*=.
25
7>6.;8
  א ויפמ ערק זאם וי א : ב אי ער ר דט אי דיש, ז אי אומזי סט ע שפרא ך ה יל ף אוועי ל עבל פאר אי וי א . יך ב ע ט בי רו פט .1
800
650
4359 .-2,*2-דא ר עב עמ מ ער יר א ז ענט א עמ מ בער, ר ע ט בי ופט. 1
877
626
9298 אל ע רעד אנ ע בי ע ט רופ ט
7*5 אויב אי ןא ט ענ ז ר 1
800
499
1275
নজরিদন: যিদআপিনবাংলায়কথাবেলনতাহেলআপনারজনƟ িবনামূেলƟরসাহাযƟ উপলভƟ রেয়েছ।আপিন125-
.-2,*2-
এরসদসƟ হেলঅনুƣহকের  
ন˘েরĺফানক˙ন।আপিন 5*7
এরসদসƟ হেলঅনুƣহকের 
ন˘েরĺফানক˙ন।অনƟানƟ সমʅ ƵেɬরজনƟ
অনুƣহকের  
ন˘েরকলক˙ন। Uwaga: jeśli mówisz po polsku, możesz z bezpłatnej pomocy językowej. Jeśli jesteś członkiem ubezpieczenia Health Plus lub Managed Medicaid, zadzwoń pod nr  Jeśli jesteś członkiem ubezpieczenia Essential Plan, zadzwoń pod nr 9298. Pozostałe osoby powinny dzwonić pod nr  125-
ﺒﯿﻪﻨﺗ : إذا ﻛ ﻨ ﻨﻛ ا ذإ .ﻚﻟﺔ ﺣﺎﺘﻣﺔ ﯿﻧﺎﺠﻤﻟاﺔ ﻳﻮﻐﻠﻟا ة ﺪﻋﺎﺴﻤﻟا ن ﺈﻓ ، ﺔﯿﺑﺮﻌﻟاﺔ ﻐﻠﻟا ث ﺪﺤﺘﺗﺖ ﻲﻓ ا ًﻮﻀﻋﺖ ﺟﺮﻳ ، ﻰ اﻻ ﻠﻋ ل ﺎﺼﺗ ﻰ اﻟ ﺮ ﻗﻢ 1
800
650
4359 إذا ﻛﻨﺖ ﻋﻀﻮا ﻓﻲ أو ﺟﺮﻳ ، ﻰ اﻻ ﺗﺼﺎ ﻠﻋ ل ﻰ اﻟ ﻢ ﻗﺮ اﻟ ﺮﻗﻢ 1
877
626
9298 .ﯿﺠﻤﻟ ﻊ اﻟ ﺮاﻣﺒ ﺞ اﻷ ﺮىﺧ ﻠﻋ لﺎﺼﻻﺗ اﻰﺟﺮﻳ ، ﻰ 7*5 .1
800
499
1275 ---PAGE BREAK---  5*7
?.>255.C
*99.5.;
5.
  ﻧﻮٹ : ا ﮔﺮ آپ ا ﻮﻟﺑ و رد ﺘﮯ ﻮ ﺗﮟﯿﮨ آپ ﮐ ﮯﻟ ﯿﮯ ﻣ ﻔﺖ ﻣ ﯿﮟ زﺑﺎن ﮐ ﯽ ﻣﺪد دﺳ ﺘﯿ ﺎب ﺮ اﮔ ۔ﮯﮨ آپ ﭘﺮ ﮐﺎ ل ۔ اﮟﮐﺮﯾ ﮔﺮ آپ ﯾﺎ
1=5*.
-5211
800
650
4359 ﮨﺮﺒﻣﻤ ﯿﮟ ﺮاﺑﻮﺗ ه ﮐ ﺮم 7*5 ﭘﺮ ﮐﺎ ل ﮟﮐﺮﯾ ۔ ﺑﺎ ﻗﯽﺳﺒﮭ ﺮاﺑ گﻟﻮﯽ ه ﮐ ﺮم1
877
626
9298 ﮐﮯ ﮨﺮﺒﻣﻤ ﯿﮟ اهﺮﺑﺗﻮ ﮐﺮﯾﻢ ﭘﺮ ﮐﺎ ۔ﮟﯾﺮ ل ﮐ800
499
1275 >70
7*0<*<*52=*
4*
70
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6*B
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4*70
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=>5870
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62B.6+;8
70
125-
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  >70
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70
<<.7=2*5
5*7
6*70B*;270
=>6*@*0
<*
  Προσοχή: Αν μιλάτε Ελληνικά μπορούμε να σας προσφέρουμε βοήθεια στη γλώσσα σας δωρεάν. Αν είστε μέλος των προγραμμάτων Child Health Plus ή Managed Medicaid, καλέστε στο 4359. Αν είστε μέλος του προγράμματος Essential Plan, καλέστε στο 9298. Διαφορετικά, καλέστε στο  I<.
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=I
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5>=.62
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7>6;27
 By A11y Updated at 10:36 am, Mar 23, 2018